Maintaining healthy teeth does not totally describe the importance of oral health. Oral health is concerned with maintaining the health of the craniofacial complex, the teeth and gums as well as the tissues of the face and head that surround the mouth. Oral, dental, and craniofacial diseases and conditions include tooth loss, diminished salivary functions, oral-facial pain, oral and pharangeal cancers, mucosal diseases and functional limitations of prosthetic replacements. These oral health impairments can diminish one’s social interactions, self-esteem and self-image and have a dramatic effect on a person’s quality of life. Oral, dental, and craniofacial diseases and conditions disproportionately affect the elderly and frail elders are particularly vulnerable to increased morbidity due to oral infections.

The first Surgeon General’s Report on Oral Health in America was a landmark document which emphasized the interaction between oral health and general health. A general lack of awareness of the links that exist between oral health conditions and one’s overall health status affects health care decisions on an individual, provider and policy level. This broader focus on oral health reflects a biopsychosocial model, and creates new opportunities to promote interdisciplinary partnerships among oral health providers and medical health providers. A paradigm depicting the determinants of health (oral health and general health) is shown in Figure 1 below.

Bibliography

1. What are key determinants that influence oral and general health?

The major factors that determine oral and general health are individual biology and genetics; the environment, including its physical and socioeconomic aspects; personal behaviors and lifestyle; access to care; and the organization of healthcare. These factors interact over the life-span and determine the health of individuals, population groups, and communities.

2. How does the geriatric population fit into the paradigm?

Aging is not a disease, but it does increase our susceptibility to disease. The common chronic diseases that affect older adults, and the medications and treatments taken to alleviate these conditions, can affect the health of the oral cavity. Individuals who have physical or functional disabilities, or are medically compromised are at a greater risk for oral diseases. As with medical diseases, dental diseases have strong behavioral, cultural and social components. Adults over the age of 65 have the highest proportion of out of pocket dental expenses; Medicaid and Medicare dental coverage is virtually non-existent. These structural weaknesses in the health care system adversely affect access to care. Conversely, oral health problems can affect ones’ overall health. Individuals with diabetes and heart disease are at greater risk from oral infections associated with periodontal disease. The mouth reflects general health and well-being. Many chronic diseases have oral manifestations and may show initial signs of clinical disease. All of these factors interact and determine the oral and general health of older adults.

3. Why is oral health a critical component of staying healthy in older adults?

Nutrition
Oral health can play a major role in the nutrition of older adults. The elderly are at increased risk for developing nutritional disorders; nutritional deficiencies have oral signs and symptoms. Oral facial pain caused by infection, trauma, ill-fitting prosthesis or salivary dysfunction may adversely affect food and fluid intake.

Systemic Disease
The elderly are more susceptible to systemic conditions that can lead to oral and maxillofacial pathology. These conditions directly or indirectly lead to malnutrition, altered communication, susceptibility to infectious diseases and diminished quality of life.

Pharmaceuticals
The oral cavity and its functions can be adversely affected by many medications taken to treat systemic conditions. Polypharmacy is prevalent in the elderly and is also associated with nutritional deficiencies. Salivary dysfunction or dry mouth and taste disorders are common sequela of many medications taken by older adults (i.e., anticholnergic medications).

Biological
The oral cavity is a portal of entry as well as the site of disease for microbrial infections that affect general health status. Immunocompromised elders and nursing home elders are at greater risk for general morbidity due to oral infections. Oral diseases give rise to pathogens that can become bloodborne or aspirated into the lungs leading to life-threatening conditions.

4. What are oral signs and symptoms of common nutritional deficiencies in older adults?

Nutritional Deficiencies with Oral Sequelae
Mineral/Vitamin Deficiency	Oral Sequela
Calcium	Skelatal osteoporosis and osteopenia, including the lower jaw, particularly lower jaw with total tooth loss
Vitamin B	Tongue, gingival, lip and mucous membrane changes. Niacin deficiency may cause the tongue to become swollen
Vitamin C	Ulcerated, edematous, and bleeding gingival tissues with halitosis
Vitamin D	Complication of calcium metabolism (skeletal osteopenia and osteoporosis)
Zinc	Taste changes

5. List oral symptoms caused by systemic conditions.

Systemic disease can affect the health of the oral-facial region. The following is an overview of some of the most common systemic conditions with associated oral manifestations.

Oral Manifestation Due to Systemic Conditions
Systemic Condition	Cause	Oral Manifestation
Coagulation disorders	Anticoagulation therapy Chemotherapy Liver cirrhosis Renal Disease	Increased bleeding risk
Immunosuppression	Alcoholic cirrhosis Chemotherapy Diabetes Medications (steriods, immunosuppressive agents) Organ Transplant therapy Renal disease	Microbrial infections
Radiation sequela	Head and Neck Radiation	Salivary dysfunction Mucositis Increased caries risk Dysphagia Dysguesia Difficulty with mastication Microbial infections Impaired denture retention
Steroid therapy	Autoimmune diseases Organ transplant therapy	Microbial infections Increased risk for adrenal insufficiency

6. What are some of the oral sequelae of medication intake for systemic diseases?

Drug Category	Drug	Oral Problem
Analgesics	Aspirin NSAIDs Barbiturates, codeine	Hemorrhage, erythema multiforme Hemorrhage Erythema multiforme
Antibiotics	All Erythromycin Penicillin	Oral candidiasis Hypersensitivity reaction, vesticuloulcerative ..stomatitis
Anticoagulants	All	Hemorrhage
Antihypertensives	All Calcium channel blockers ACE inhibitors Thiazide diuretics Captopril, Diazoxide	Salivary dysfunction Gingival enlargement Vesticuloulcerative stomatitis, pemphigus vulgaris Lichenoid mucosal reaction Taste disorders
Anti-Parkinsonian	All	Salivary dysfunction
Anxiolytics	Bensodiazepines	Salivary dysfunction
Vasodilators	Nitoglycerine Patch	Taste disorders
Psychotherapeutics	All Glutehimide, Meprobamate Phenothiazines	Salivary dysfunction Erythema multiforme Oral pigmentation, tardive dyskinesia
Corticosteroids	All	Oral candidiasis, recurrent oral viral infections

The oral health of elders residing in nursing homes is very poor and dental caries is the major cause of tooth loss. Consistent daily removal of plaque and cleansing of dentures would dramatically improve the oral health status of these patients. Unfortunately, the oral healthcare of the older institutionalized elder is frequently given a low priority. Interdisciplinary cooperation implemented by hospital administrators, nursing staff, dentist, and dental hygienist can reduce the risk of dental caries, gingival disease and tooth loss among nursing home elders. The following procedures are suggested to improve the oral health of nursing home elders:

Controlling Dental Plaque

Residents with teeth:
Resident’s teeth should be brushed in the morning and prior to going to bed at night. A regular manual toothbrush may not be helpful for residents with disabilities that affect manual dexterity or for a caregiver to provide oral hygiene care. Manual toothbrushes can be adapted to accommodate the needs of the patient. The handle can be built up with a wash cloth, aluminum foil, a sponge hair roller, or inserted in a tennis ball. Electric toothbrushes may also be considered.

Residents with partial tooth loss or total tooth loss:
Dentures and partial dentures should be thoroughly cleansed daily with a denture brush or toothbrush. To reduce the risk of breaking, a washcloth should be placed in the sink before cleaning under running water. Dentures should be removed at night and soaked in a denture cleanser. All prosthesis should be labeled with the residents’ name.
Therapeutic Agents - Fluoride gels or the antiseptic chlorexidine gel may be applied to teeth using a foam brush (Toothette). This procedure may be used for patients in which tooth brushing is not possible. Foam brushes are not as effective as tooth brushing, but do provide a mechanism for controlling plaque in difficult patients.

Healthcare Practitioner Training

Nursing home staff should request in-service training by a dentist or dental hygienist regarding the identification of common signs of oral problems and the mechanisms of daily oral and denture hygiene for residents.

8. What recommendations for oral care can medical providers give caregivers for Alzheimer’s disease patients?

Medical providers should refer patients to a dentist as soon as possible after diagnosis of Alzheimer’s Disease. Patients diagnosed in the mild disease category should be seen by the dentist as soon as possible after diagnosis, because oral self-care skills increasingly decline, as the ability to cooperate as Alzheimer’s disease progresses. Patients who are in the severe stages may not be aware of oral problems or capable of expressing having oral pain. These patients should be referred to the dentist for assessment and may require more frequent recall visits to ensure there are no acute problems and oral hygiene care is adequate. The caregiver should be trained by the dental care team to provide daily oral hygiene for the Alzheimer’s patient, with the expectation of eventually assuming this role completely as the patient’s condition deteriorates. Additionally, caregivers of all Alzheimer’s patients should be trained by the dental care team to perform an oral screening examination to note any changes in the following oral-facial regions: The face and neck, lips, inside cheeks and lips, roof of mouth, floor of mouth, gums, teeth or ill-fitting prosthesis. The medical provider can assist the oral care provider in increasing oral and general health awareness to caregivers. The following recommendations regarding oral health care can be given by medical providers to caregivers:

• Establish a regular time each day for mouth care
• Break up the steps for cleaning into small simple steps for the patient, reminding the person one step at a time
• Explain what you are doing in a gentle, calm manner
• Place a small list of step-by-step instructions on a piece of paper and post it in the bathroom, if the person can still read
• Keep labeled mouth care supplies in the same place all the time
• Do not assume the person will remember the next day what he or she did today
• Maintain professional dental care visits as recommended by the dentist
• Perform monthly oral screening examinations and seek professional dental care immediately if any changes are noted in the oral-facial region
  

9. What can oral and medical providers do to promote the oral and general health of older adults?

• Health care providers can successfully deliver tobacco cessation and other health promotion programs in their offices, contributing to both overall health and oral health
• Community –based programs for oral and general health care provide opportunities for collaborations between medical practitioners and dental practitioners at the local and state level
• Nursing staff and medical providers should be trained to recognize common signs and symptoms of oral conditions that require a referral to the dentist
• Medical and oral healthcare providers should form partnerships to spread awareness to policymakers of the importance of oral health to ones’ overall health and support extended federal and state assistance programs for oral health services

U.S. Department of Health and Human Services (2000). Oral Health in America: A Report of the Surgeon General - Executive Summary. Rockville, MD:U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.

U.S. Department of Health and Human Services (2000 Jan). Health People 2010 (conference edition in two volumes). Washington, DC:U.S. Department of Health and Human Services.

Henry R. G., Wekstein D.R. (1997). Providing dental care for patients with Alzheimer’s Disease. Dent Clin N Am, 41, 915-942.

Ghezzi E.M., Ship J.A. (2000). Systemic diseases and their treatments in the elderly: Impact on oral health. J Public Health Dent, 60(4), 289-296.

Ship J. A. (2001). Geriatric oral medicine. Alpha Omegan, 94, 44-51.

Saunders M. J. (1997). Nutrition and oral health in the elderly. Dent Clin N Am, 41, 681-698.

Ship J.A. (2002). Improving oral health in older people. Journal American Geriatrics Society, 50:1454-1455.

Erikson L. (1997). Oral health promotion and prevention for older adults. Dental Clin N Am, 41. 727-750.

MacEntee M.I. (2000). Oral care for successful aging in long-term care. J Public Health Dent, 60 (4), 326-29.

Dr. Ann Slaughter can be contacted at yas@pobox.upenn.edu
For more information about the GeroTIPS modules, please email Monda Spool, HCGNE Administrator.